The coding of doctor’s office visits can be confusing – and ever-changing.
Every year, regulations and guidelines change, and it can be difficult for providers to keep up. Most teams have coding staff with limited training, so some changes go unrecognized.
The flip side of encryption is compliance – and the growing risk of compliance audits that can have serious financial consequences for supplier groups if violations are discovered.
Increase top line revenue
“In healthcare, you only get paid for what you record and the codes you send,” says Dr. Bruce Cohen, a surgeon and former CEO at OrthoCarolina in Charlotte, North Carolina. . “Coding the right encounters combined with the right documentation can really increase top line revenue.
“Too often, providers are working under legacy rules and procedures and are missing out on significant revenue opportunities through tokenizing their office visits,” he continued. “This is especially evident in the primary care sector because the majority of practice income comes from clinic visits.”
AI-based programs that provide balanced and consistent coding instructions in real-time can be an invaluable addition to the practice, Cohen said.
“This does not mean eliminating the jobs of programmers,” he explains; it expands the visibility and accuracy of every charge made based on evaluation and management (E/M) coding. “It also brings a level of compliance to documentation that is not present in the current practice environment. Once annual coding requirements are established, the AI-based system integrates and implements those changes in real time.”
Switch to AI system
OrthoCarolina used vendor MontecitoPLUS’s Calm Waters AI coding system to support its coding efforts.
“Calm Waters AI is used by physicians, physician assistants, medical coders, and several others to review physician documentation and assign CPT and ICD-10 codes for billing,” Cohen explains. appropriate for the services provided”. “Coding is a complex and often confusing process due to both the large number of separate codes and the number of regulations and guidelines that change from year to year and within each year.
“For E/M services, part of the physician’s daily workflow is to review each patient encounter and provide documentation of the patient’s symptoms, history, and diagnosis,” he continued. patient, along with treatment recommendations”. “Based on the diagnosis – including the accuracy and complexity of the problems being diagnosed – the complexity of the data needed to make the diagnosis and the level of risk of complications and morbidity/ death in patient, physician dictates level of medical decision-making.” (MDM) to the meeting.”
MDM types – low complexity, moderate complexity, and high complexity – guide coding and billing decisions for provider services.
Integrate AI into Epic EHR
“Once the provider records the history, exam, and MDM types, the team’s coders can assign E/M codes based on this information,” says Cohen. “The give-and-take between coders and providers often prevents this from being a seamless and time-saving process. Coders may disagree with the level of MDM prescribed by their physician or their may require the physician to provide additional documentation to substantiate a given MDM’s grade and the billing associated with it.
“Because Calm Waters AI is integrated into our Epic EHR, it becomes a seamless part of physicians’ workflow,” he continued. “The system relies on artificial intelligence to review the physician’s documentation for each visit and recommend appropriate levels and coding.”
Doctors can then review the system’s recommendations and decide to accept or reject them in just a few seconds. This system helps them identify potential coding and documentation compliance issues while records are still on the physician’s computer, before they reach the coding and billing stage and errors become apparent. so it’s more difficult and time consuming to fix.
“In this way, the system helps increase accuracy and compliance, reducing the risk of denials, delays and payer audits,” notes Cohen. “In addition, the system also saves documentation time for suppliers and makes programmers’ work simpler and faster.”
What do they expect from the system?
Cohen said it’s too early in the implementation process to report any hard results, but believes the AI-powered system will deliver a significant return on investment by allowing OrthoCarolina to receive reimbursement pay for more of the time physicians spend caring for patients and by improving the accuracy of E/M coding.
Cohen has some advice for colleagues when implementing or using AI-based systems for encryption.
“The first step is to reassure your coding staff that this should not be considered a threat from a job security standpoint,” he said. “It must reaffirm the importance of their work and give them the ability to expand their scope without exceeding their current capacity.
He added: “Most teams survey the accuracy of their coding through audits or on-site inspections; On the contrary, we can use these AI-based systems in every encounter, which cannot be achieved with current staffing.”
Embrace technology
The second piece of advice he gave was to adopt technology as early as possible.
“In healthcare, we will continue to experience downward pressure on reimbursement and increased demand for medical decision-making and documentation,” he said. “Why don’t we use AI-based systems to optimize reimbursement for these cases?
“Providers are doing the work and are increasingly being asked to do more for the same reimbursement codes; why aren’t they fairly compensated for that trouble?” he concluded. “I really encourage administrators and healthcare providers to look at technology to assist us in the areas of practice management and documentation.”
